Focus on Non-osteoporotic Post-menopausal Women with Asymptomatic Primary Hyperparathyroidism: A Monocentric Series.

OBJECTIVE: Primary Hyperparathyroidism (PHPT) is a common disease, frequently diagnosed in post-menopausal women, among whom Osteoporosis (OP) is a common finding. To date, no study has specifically evaluated the asymptomatic PHPT (aPHPT) patients without OP, in particular post-menopausal women who are exposed to an increased risk of developing OP. DESIGN: This study involved a retrospective cross-sectional evaluation. PATIENTS: From our database of 500 consecutive patients diagnosed with PHPT, 178 postmenopausal aPHPT were retrieved. RESULTS: The clinical, biochemical, and imaging data of the 85 patients without OP were not different from those of the 93 with OP, except for bone alkaline phosphatase (significantly higher in the latter group). Among these 85 patients without OP, the 45 patients meeting surgical criteria for parathyroidectomy had significantly higher values of serum PTH (240 vs. 99 ng/L, p =0.03) and calcium (total, 11.2 ± 0.7 vs. 10.6 ± 0.4 mg/dL, p <0.001; ionized, 1.45 ± 0.12 vs. 1.36 ± 0.8 mmol/L, p =0.044) and lower values of serum phosphate (2.57 ± 0.7 vs. 2.94 ± 0.5 mg/dL, p =0.009) and eGFR (68.5 ± 23.8 vs 80.8 ± 14.4 mL/min/1.73 m2, p =0.006) than the 40 aPHPT patients not meeting surgical criteria, without any difference in densitometric data and calculated fracture risk. CONCLUSION: In our series, post-menopausal aPHPT patients without OP accounted for almost a sixth of the whole PHPT series. About half of these patients did not meet surgical criteria, but their T scores and 10-year fracture risk calculated by FRAX were not significantly different from post-menopausal aPHPT without OP meeting surgical criteria.

Pituitary Apoplexy With Transition to Acute Hypophysitis in a Patient With Sars-CoV-2 Pneumonia.

COVID-19 is a systemic disease associated with respiratory insufficiency, systemic inflammation, as well as coagulation, neurological, and endocrine disorders. Among them pituitary apoplexy (PA) as well as, more rarely, acute hypophysitis (AH) have been reported. In the present report, we described a case of PA in an 84-year-old man with SARS-CoV-2 pneumonia, with a previous unknown pituitary adenoma and a possible but not confirmed overlap with transitory AH. After reviewing the available literature, we discuss the potential clinical and pathophysiological relationship between PA and AH. Furthermore, we focus on the neuroradiological features of pituitary lesions in the presence of SARS-CoV-2 infection.

Recurrence and mortality rate in an Italian multi-center case series of parathyroid atypical adenomas and carcinomas.

Introduction: There are few data regarding the clinical outcome of patients with parathyroid carcinoma (PC) and atypical adenoma (AA) after surgery. Aim of our study was to investigate disease recurrence and mortality rate as well as their predictors in a series of patients with PC or AA. Methods: Clinical and biochemical parameters, histological features, incidence of disease recurrence and mortality rate were retrospectively assessed in 39 patients (51% males, mean age 56.2 ± 17.2 years) diagnosed with PC (n=24) or AA (n=15) and followed up for 6.8 ± 5.0 years after surgery. Results: No differences in baseline characteristics were registered between the two groups, except for higher KI67 values in PC than AA (6.9 ± 3.9% vs 3.4 ± 2.1%, p<0.01). Eight patients (21%) experienced recurrence after a mean follow-up of 5.1 ± 2.7 years, with higher relapse rate in PC than AA (25% vs 13%), though this difference did not reach statistical significance. Mortality rate was 10% in the whole sample, without significant differences between PC and AA. Relapsing cases had been undergone the most extensive surgery more frequently and they had a higher mortality rate in comparison to non relapsing patients (38% vs 6% and 38% vs 3%, respectively, p<0.03 for both). In comparison to survivors, deceased patients were submitted to the most extensive surgery more frequently (50% vs 9%), they were older (74.8 ± 4.6 vs 53.2 ± 16.3 years), and they had higher KI67 values (11.7 ± 4.9 vs 4.8 ± 2.8, p<0.03 for all comparisons). Conclusions: During seven-year follow-up after surgery, no significant differences in recurrence and mortality rate were observed between PC and AA patients. Death was associated with disease relapse, older age and higher KI67 values. These findings suggest a similar and careful long-term follow-up in both parathyroid tumors, especially in older patients, and emphasize the need of further studies in large cohorts to throw light on this crucial clinical issue.

A Multi-professional Approach for Transition of Care at Discharge in Hyperglycemic Inpatients with COVID-19: A Single Center Study.

BACKGROUND: The discharge from the hospital of insulin-treated hyperglycemic patients is always challenging. This is even more so in patients requiring glucocorticoid treatment, such as those with COVID-19. PATIENTS AND METHODS: A retrospective monocentric study of 23 inpatients was conducted with newly diagnosed or already known diabetes mellitus (DM) who were naïve to insulin treatment, and who were hospitalized with COVID-19 in non-critical settings and then discharged. Patients were followed up for one month after discharge for the management of insulin treatment by a multi-professional team through phone consultations. RESULTS: Insulin prescriptions at discharge were 24.6 ± 14 U/day injected in 2 ± 1.5 daily shots. A mean of three phone consultations was required. One month later, the mean insulin reduction was 1.5 ± 1.3 shots and 6 ± 5 U/day. All patients reached their glycemic target without hypoglycemic events, drop-outs, or readmissions. CONCLUSION: This study demonstrates the feasibility, efficacy, and safety of a multi-professional approach through telemedicine for managing DM patients after discharge during COVID-19.

Post-pregnancy recurrent biliary colic with intraoperative diagnosis of limy bile syndrome.

INTRODUCTION: Limy bile syndrome (LBS) is an unusual condition in which gallbladder and/or bile ducts are filled with paste-like radiopaque material with a high calcium carbonate content. It can be rarely associated with PTH disorder and hypercalcemia. PRESENTATION OF CASE: A 35-year-old woman presented with epigastric and right hypochondrium pain since a few hours. Similar attacks occurred in the past months soon after a pregnancy with vaginal delivery. Laboratory findings were not significant. The abdominal ultrasound highlighted a micro-lithiasis of gallbladder without complications. Considering the recurrent biliary attacks, laparoscopic cholecystectomy was performed with intraoperative diagnosis of LBS. A subsequent endocrinological screening highlighted a normocalcemic hyperparathyroidism associated with Vitamin D deficiency, likely related to the recent pregnancy and not to LBS. DISCUSSION: LBS is a rare condition with not clear etiology, frequently associated with cholelithiasis, of which it shares clinical presentation and potential complications. Diagnosis of LBS is based on abdominal X-ray/computed tomography scan, or it could be an intraoperative finding. The gold standard treatment is represented by laparoscopic cholecystectomy. The pregnancy with its related cholestatic phenotype could facilitate the LBS manifestation. An endocrinological screening should be performed to rule out a concomitant calcium metabolism disorder. CONCLUSION: Knowledge of this rare condition could help general surgeons handle it properly.

Persistence of Elevated Procalcitonin in a Patient with Coronavirus Disease 2019 Uncovered a Diagnosis of Medullary Thyroid Carcinoma.

OBJECTIVE: During the ongoing coronavirus disease 2019 pandemic, procalcitonin (PCT) levels have proven useful in assisting clinicians to diagnose bacterial superinfection. However, in the absence of signs of infection or at the resolution thereof, inappropriately and persistently high PCT levels may suggest and reveal the presence of other pathologies. We report a patient with severe acute respiratory syndrome coronavirus 2 pneumonia with initially elevated PCT levels that persisted during recovery, prompting the diagnosis of medullary thyroid carcinoma (MTC). METHODS: A 43-year-old man presented with a 2-day history of fever, sneezing, sore throat, and dry cough. His PCT was 94 ng/mL (normal value, 0.00-0.10 ng/mL), and he was positive for severe acute respiratory syndrome coronavirus 2 RNA. RESULTS: Empirical antibiotic therapy was administered for 7 days, but despite a clinical improvement, serum PCT remained high (84 ng/mL). Serum calcitonin (CTN) was 2120 pg/mL (normal, ≤12 pg/mL). Cytologic examination of thyroid nodules and CTN measurement of the aspiration needle washout confirmed MTC. The patient underwent total thyroidectomy with bilateral cervical lymph node dissection. Lowered CTN (986 pg/mL) and PCT (16 ng/mL) levels were observed 48 hours after surgery. A close follow-up was planned following the results of RET gene analysis. CONCLUSION: PCT can be a useful biochemical marker of MTC suspicion in patients with inflammatory conditions and persistently elevated PCT, even after resolution. In our case, high levels of PCT in a patient with coronavirus disease 2019 pneumonia without signs of bacterial infection led to MTC diagnosis.

Baseline cortisol and the efficacy of antiglucocorticoid treatment in mood disorders: A meta-analysis.

INTRODUCTION: Hyperactivity of the Hypothalamic-Pituitary-Adrenal (HPA) axis and high cortisol levels have been widely reported in patients with mood disorders but previous clinical trials investigating the efficacy of antiglucocorticoid treatment in this population have reported inconsistent findings. The inconsistencies among these studies may be because not all patients with mood disorders have increased HPA axis activity and therefore might not benefit from antiglucocorticoid treatment. The aim of this meta-analysis was to investigate whether baseline cortisol levels influence the efficacy of antiglucocorticoid drugs in patients with mood disorders. METHODS: PubMed and Scopus databases were searched systematically up to October 2018. We included studies using metyrapone, ketoconazole or mifepristone in patients with major depressive disorder, bipolar disorder and major depressive disorder with psychotic symptoms. We tested for a difference in cortisol levels between responders (a reduction equal to or greater than 30% on depression scales following antiglucocorticoid treatment) and non-responders (a reduction of less than 30% on depression scales). We performed a meta-analysis to look specifically at differences in cortisol levels in the sample of patients treated with cortisol synthesis inhibitors (metyrapone and ketoconazole) and in those treated with glucocorticoid receptor (GR) antagonist (mifepristone). RESULTS: We were able to retrieve data from 11 of the 16 selected studies and to include 9 studies in the meta-analysis. In the overall sample (N = 846), responders had similar baseline cortisol levels compared with non-responders (standardised mean difference, SMD = -0.03, 95% CI [-0.17, 0.12], p = 0.75). In the group of patients treated with cortisol synthesis inhibitors, responders (N = 109) had significantly higher peripheral baseline cortisol levels compared with non-responders (SMD = 0.42, 95% CI [0.01, 0.83], p = 0.047). In the group of patients treated with a GR antagonist (N = 737), both responders and non-responders had similar baseline cortisol levels (SMD = -0.09, 95% CI [-0.25, 0.07], p = 0.26). CONCLUSION: Our data suggest that only patients with higher cortisol levels at baseline benefit from treatment with cortisol synthesis inhibitors and support a potential role for cortisol as a predictive biomarker for treatment with cortisol synthesis inhibitors in patients with mood disorders.

Classical complications of primary hyperparathyroidism.

Traditionally, classical complications of primary hyperparathyroidism are mainly represented by skeletal, kidney and gastrointestinal involvement. The old picture of osteitis fibrosa cystica is no longer commonly seen, at least in the western world. However, new imagining techniques have highlighted deterioration of skeletal tissue in patients with primary hyperparathyroidism not captured by traditional DXA measurement. Concerning the kidney, the most common consequences of excessive parathyroid hormone secretion are hypercalciuria and kidney stones; however, the exact pathogenesis of urinary stone formation is still unknown. The 2013 International Congress on the management of Asymptomatic Primary Hyperparathyroidism, emphasized the role of imaging techniques for early discovery of both skeletal and renal complications in asymptomatic patients. Gastrointestinal manifestations include acid-peptic disease, constipation, pancreatitis and gall stone disease. More studies are needed in this area to find the exact pathophysiological mechanism underlying these manifestations and the effect of parathyroid surgery.

Sex Difference in the Clinical Presentation of Primary Hyperparathyroidism: Influence of Menopausal Status.

Context: Female-to-male ratio in primary hyperparathyroidism (PHPT) is 3:1, but data on sex impact on the clinical presentation are limited. Design: We evaluated, retrospectively, sex difference in biochemistry and clinical presentation at diagnosis in a monocentric series of 417 patients with PHPT: 93 men (58.6 ± 14.5 years), and 324 women (61.7 ± 12.8 years), of whom 54 were premenopausal (pre-F) and 270 postmenopausal (post-F). Results: Men were significantly younger (P = 0.046) and more frequently symptomatic than women (62.3% vs 47%, P = 0.016). No sex difference was found in serum parathyroid hormone, calcium, creatinine, 25-hydroxy-vitamin D, and urinary calcium levels, whereas serum phosphate was higher in women. Nephrolithiasis (detected by imaging or history of passing stones) was more frequent in men (50.5% vs 33% in women, P = 0.003) and osteoporosis (T-score <-2.5 at any site) was more frequent in women (52.2% vs 35.5% in men, P = 0.0066). Symptomatic patients were 43.3%, 64.8%, and 62.3% in post-F women, pre-F women, and men, respectively. Kidney stones were less frequent and osteoporosis more frequent in post-F women than in pre-F women (28.1% vs 59.2% and 58.9% vs 18.5%, respectively). After combining symptomatic and asymptomatic patients meeting surgical criteria recommended by current guidelines, no sex difference was observed in the proportion of patients to be referred for surgery (84.6% in men vs 84.9% in women). Conclusion: Biochemical activity of PHPT seems to be independent of sex, but clinical presentation is different, mostly due to menopausal state. However, surgical referral was indicated equally in men and women.

Mindfulness-Based Stress Reduction Program on Chronic Low-Back Pain: A Study Investigating the Impact on Endocrine, Physical, and Psychologic Functioning.

OBJECTIVE: To explore the impact of the Mindfulness-Based Stress Reduction (MBSR) program on pain severity and endocrine, physical, and psychologic functioning in patients with chronic low-back pain (CLBP). METHODS: A total of 28 participants were enrolled in the study between January and June 2014; 17 participants were sequentially sampled for an 8-week MBSR program, and 11 were placed on a waitlist control group. Pain severity, quality of life (QOL), global psychologic functioning, and depression were assessed at baseline, at the end of treatment, and 4-5 months post-treatment for both groups. Morning and evening salivary cortisol was assessed at multiple time points in participants in the MBSR group. RESULTS: In comparison with baseline, evening cortisol release showed a significant increase post-treatment. Significant differences between groups were found in pain severity. Medium-to-large effect sizes were found for between-group differences in both pain severity and QOL. CONCLUSIONS: The cortisol increase in the MBSR group is a promising finding, in the context of CLBP hypocortisolism. Data show that the effects of the MBSR treatment may take time to surface. However, due to small sample size, decisive interpretation of findings is limited. Nevertheless, the MBSR program may show promise for CLBP and should be an avenue for further investigation through larger clinical trials within healthcare systems.

Forearm DXA Increases the Rate of Patients With Asymptomatic Primary Hyperparathyroidism Meeting Surgical Criteria.

INTRODUCTION: A reduction in bone mineral density (BMD) is common in primary hyperparathyroidism (PHPT), above all at cortical sites. Guidelines for the management of asymptomatic PHPT (aPHPT) recommend a BMD evaluation at the lumbar spine, hip, and forearm. Surgery is recommended for patients with a T-score less than or equal to -2.5 at any of these sites. However, a BMD evaluation at the forearm is not routinely performed. AIM: To evaluate the impact of measuring forearm BMD in the clinical management of aPHPT. SUBJECTS AND METHODS: We retrospectively reviewed a prospective database of 172 patients with aPHPT, selecting the 116 patients in whom a dual x-ray absorptiometry (DXA) scan had been performed at all 3 sites. RESULTS: Seventy-four out of 116 patients had a densitometric diagnosis of osteoporosis (OP) at any site, and the forearm was the only site involved in 13/74 (group A, 17.6% of osteoporotic patients and 11.2% of the whole aPHPT cohort). Patients belonging to group A were significantly older than the other aPHPT patients, whereas no difference was found in biochemical measurements. Six out of 13 patients belonging to group A (5.2% of the whole aPHPT cohort) fulfilled surgical criteria based only on a forearm T-score. CONCLUSIONS: DXA at 3 sites revealed OP at the forearm, but not at the other sites, in 11.2% of aPHPT patients. Half of these cases met surgical criteria based on this one factor alone. These patients did not show any clinical (except age) or biochemical differences from the other patients. The implementation of forearm DXA increases the rate of patients with aPHPT meeting surgical criteria.

VITAMIN D DEFICIENCY DOES NOT AFFECT THE LIKELIHOOD OF PRESURGICAL LOCALIZATION IN ASYMPTOMATIC PRIMARY HYPERPARATHYROIDISM.

OBJECTIVE: Vitamin D deficiency (VDD) was previously associated with larger adenoma size in primary hyperparathyroidism (PHPT), but this topic was not addressed in patients with the mild/asymptomatic form of the disease (aPHPT). METHODS: We retrospectively retrieved from our series of patients affected by PHPT, 96 consecutive subjects with aPHPT in whom 25-hydroxyvitamin D (25OHD) levels had been assayed and compared those results with localizing imaging studies. RESULTS: Twenty-five of 96 patients had VDD (25OHD <20 ng/mL), but positive ultrasound and scintigraphic studies were not different between patients with and without VDD (52.3% versus 55.7% and 42.9% versus 52.4%, respectively). Upon logistic regression analysis, after adjusting for different variables, including the presence of goiter, VDD was not an independent predictor of localization by imaging studies. CONCLUSION: VDD does not affect the likelihood of positive pre-operative imaging in aPHPT and the consequent surgical decisions.

KDIGO CATEGORIES OF GLOMERULAR FILTRATION RATE AND PARATHYROID HORMONE SECRETION IN PRIMARY HYPERPARATHYROIDISM.

OBJECTIVE: The recent Fourth Workshop on the Management of Asymptomatic primary hyperparathyroidism (PHPT) maintained the threshold of 60 mL/min for decreased renal function, below which surgery is recommended. This study investigated the relationship between different stages of renal insufficiency and parathyroid hormone (PTH) levels in an updated case series of PHPT patients. METHODS: This was a retrospective, cross-sectional study involving 379 consecutive PHPT patients. Biochemical evaluation included total and ionized serum calcium, phosphate, creatinine, immunoreactive intact PTH, and 25-hydroxyvitamin D3 (25[OH]D3) levels in the fasting state. Glomerular filtration rate (GFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. RESULTS: Mean CKD-EPI estimated GFR was 81.9 ± 20.3 mL/min/1.73 m(2), and median GFR was 84.0 mL/min/1.73 m(2) (interquartile range, 26.8 mL/min/1.73 m(2)). The patients were divided into 5 groups according to the Kidney Disease: Improving Global Outcomes 2012 guidelines: group 1 with normal or increased GFR (>90 mL/min/1.73 m(2)); group 2 with mild GFR decrease (60 to 89 mL/min/1.73 m(2)); group 3a with mild to moderate GFR decrease (45 to 59 mL/min/1.73 m(2)); group 3b with moderate to severe GFR decrease (30 to 44 mL/min/1.73 m(2)); and group 4 with severe GFR decrease (<30 mL/min/1.73 m(2)). Among the 5 groups of patients, serum calcium levels were different (P = .025), whereas 25(OH)D3 levels were not (P = .36). PTH levels were comparable across groups 1 through 3a, but they were significantly higher in groups 3b and 4 (P<.0001). CONCLUSION: In our series of PHPT patients, PTH levels did not rise as a result of renal impairment until GFR decreased below 45 mL/min/1.73 m(2).

Silent renal stones in primary hyperparathyroidism: prevalence and clinical features.

OBJECTIVE: (1) To evaluate the prevalence of silent nephrolithiasis in patients with primary hyperparathyroidism (PHPT) compared with controls, and (2) To characterize clinically PHPT patients with silent renal stones. METHODS: We reviewed clinical data for 141 patients with PHPT and without symptoms or history of nephrolithiasis in whom renal ultrasonography was performed at diagnosis. A total of 141 sex- and age- matched subjects with abdomen ultrasonography obtained for reasons different from urinary symptoms served as controls. RESULTS: Silent nephrolithiasis was more prevalent in PHPT patients than in controls (11.35% vs. 2.13%; P = .003). Among patients with PHPT, those with silent renal stones showed higher serum calcium and parathyroid hormone levels and met surgical criteria, regardless of nephrolithiasis, more frequently than those without renal stones. CONCLUSION: The prevalence of silent nephrolithiasis is increased in patients with PHPT as compared with controls. Moreover, it seems likely that silent renal stone disease could identify a subset of PHPT patients with more severe disease. Accordingly, we suggest ultrasonographic screening of nephrolithiasis in all PHPT patients. Further studies are needed to better characterize this clinical entity.

Relationship between insulin sensitivity and bone mineral density in primary hyperparathyroidism.

INTRODUCTION: Evidence of crosstalk between bone and insulin metabolism has been identified. In primary hyperparathyroidism (PHPT), scant data exist on this relationship. AIM: To evaluate the relationship between insulin levels or sensitivity and bone mineral density (BMD) in PHPT. SUBJECT AND METHODS: Two hundred and sixty-seven patients with PHPT without known diabetes mellitus were studied. Fasting blood glucose and insulin levels as well as BMD at lumbar spine, femoral neck and forearm were measured. Insulin sensitivity was assessed using Quantitative Insulin Sensitivity Check Index (QUICKI). The same parameters were measured 2 years (interquartile range 2·8 years) after surgery (PTX) in a subgroup of patients (n = 51). RESULTS: In univariate analysis, a positive relationship between insulin levels and BMD (R = 0·17, P < 0·03) or T-score (R = 0·20, P < 0·005) was found at femoral neck level. Consequently, a negative relationship between QUICKI and femoral BMD (R = -0·20, P < 0·01) or T-score (R = -0·21, P < 0·004) was found. In multivariate analysis, when femoral BMD was the dependent variable, age (beta = -0·35, P < 0·000004), BMI (beta = 0·39, P < 0·00001), PTH (beta = -0·18, P < 0·05) and QUICKI (R = -0·15, P < 0·05) had an independent effect (R(2) = 0·29). Insulin levels and QUICKI did not change after PTX. No relationship was found between QUICKI or insulin levels at the time of diagnosis and change in BMD at any site at follow-up. CONCLUSIONS: Our data show a weak relationship between insulin levels and/or insulin sensitivity and BMD in PHPT. However, the insulin state does not influence change in bone density after PTX in PHPT.

Vitamin D status in primary hyperparathyroidism: a Southern European perspective.

BACKGROUND: Vitamin D deficiency (VDD) is common in patients with primary hyperparathyroidism (pHPT), and this could affect the clinical expression of the disease. However, few North American or North European studies have addressed this issue, showing vitamin D repletion in only about one-third of the patients. SUBJECTS AND METHODS: Vitamin D status was evaluated both in an observational study in a series of 206 consecutive patients with pHPT at diagnosis and in a case-control analysis with 113 age- and sex-matched healthy blood donors. Vitamin D status was assessed by measuring plasma 25-hydroxy-vitamin D (25OHD) levels and was defined as VDD or severe VDD if 25OHD was <20 ng/ml (<50 nm) and <10 ng/ml (<25 nm), respectively. RESULTS: No seasonal variability was observed in 25OHD levels. VDD was observed in 75 of 206 patients (36·4%). The VDD was severe in 24 of 75 patients (11·7%). There was no difference in prevalence of VDD between men and women nor between asymptomatic and 'bone and stone' symptomatic patients. 25OHD levels was negatively correlated with parathyroid hormone, ionized calcium, and bone turnover markers, and positively correlated with phosphate. 25OHD levels were also positively correlated with bone mineral density at all sites measured. In the case-control study, the overall prevalence of VDD and severe VDD was higher in patients with pHPT compared with controls (33·6% vs 10·6%, P < 0·0001, and 8·8% vs 1·8%, P = 0·0337, respectively). CONCLUSIONS: Our study shows that VDD occurs in about one-third of patients with pHPT resident in a Southern European area, a lower figure than previously reported. Moreover, VDD is related to a more severe bone disease, and its prevalence is higher in patients with pHPT than in healthy matched subjects.

Cinacalcet in the management of primary hyperparathyroidism: post marketing experience of an Italian multicentre group.

OBJECTIVE: To report the Italian experience on cinacalcet use following its approval by the European Medical Agency (EMA) to control hypercalcaemia in patients with primary hyperparathyroidism (PHPT). DESIGN: Retrospective data collection from 100 patients with sporadic (sPHPT) and 35 with familial PHPT (fPHPT) followed in eight Italian centres between October 2008 and March 2011. MEASUREMENTS: Albumin-adjusted serum calcium, PTH, 25OHD, daily cinacalcet dose and adverse events were recorded during the follow-up (1-46 months). RESULTS: Baseline serum calcium was 2·90 ± 0·27 nmol/l in sPHPT and 2·75 ± 0·17 nmol/l in fPHPT patients (P = 0·007). The cinacalcet EMA labelling was met in 53% sPHPT and 26% fPHPT patients. High surgical risk (34%), negative preoperative imaging (19%), control of hypercalcaemia before parathyroidectomy (PTx) (24%), and refusal of PTx (19%) accounted for cinacalcet prescription in 96% of sPHPT patients. Conversely, initial treatment (34%), persistent/relapsing PHPT after surgery (31%), and refusal of PTx (14%) were the indications in 79% fPHPT patients. Cinacalcet was started at 30 mg/daily in 64% of sPHPT and 91% of fPHPT and increased until normocalcaemia was reached or side effects occurred. The final daily dose ranged between 15 and 120 mg. The majority of patients (65% of sPHPT and 80% of fPHPT) become normocalcaemic. Treatment was withdrawn in six patients because of side effects. CONCLUSIONS: There is a wide heterogeneity in the prescription of cinacalcet in PHPT patients in Italy and the EMA labelling is not always followed, particularly in fPHPT patients. Cinacalcet effectively reduces serum calcium in patients with either sPHPT or fPHPT.

Neuroblastoma in the Elderly and SIADH: Case Report and Review of the Literature.

Objective. To report the rare case of a thymic neuroblastoma, in an elderly woman with SIADH at presentation. Methods. Clinical and biochemical data of the patient are presented and the pertinent literature is reviewed. Results. a 79-year-old woman was admitted into our department with worsening asthenia, severe hyponatremia (114.8 mEq/L), low plasma osmolarity (253 mEq/L), and inappropriate urinary sodium concentration (151 mEq/L). CT scan showed an a large solid inhomogeneous mass in the anterior mediastinum. (18)F-FDG-PET/CT showed uptake in the mass. On continuous 3% hypertonic saline infusion, sodium gradually increased without achieving normal values. The patient underwent surgery, followed by full normalization of sodium levels. Tumor cells were positive for neuroendocrine markers. Thymic neuroblastoma with SIADH was diagnosed. Conclusions. Neuroblastoma is an extremely rare tumor in the elderly. Contrary to children and younger adults, neuroblastoma in older adults is typically localized in the anterior mediastinum and is often associated with SIADH. Moreover, it has mainly local aggressiveness in this age group, without metastatic spread; thus radical surgery achieves cure in most cases.